Shashin Shah Md

Initial experience with a novel EUS-guided core biopsy needle (SharkCore): results of a large North American multicenter study.

Background and aims: The ability to safely and effectively obtain sufficient tissue for pathologic evaluation by using endoscopic ultrasound (EUS) guidance remains a challenge. Novel designs in EUS needles may provide for improved ability to obtain such core biopsies. The aim of this study was to evaluate the diagnostic yield of core biopsy specimens obtained using a novel EUS needle specifically designed to obtain core biopsies. Patients and methods: Multicenter retrospective review of all EUS-guided fine-needle biopsies obtained using a novel biopsy needle (SharkCore FNB needle, Medtronic, Dublin, Ireland). Data regarding patient demographics, lesion type/location, technical parameters, and diagnostic yield was obtained. Results: A total of 250 lesions were biopsied in 226 patients (Median age 66 years; 113 (50 %) male). Median size of all lesions (mm): 26 (2 – 150). Overall, a cytologic diagnosis was rendered in 81 % specimens with a median number of 3 passes. When rapid onsite cytologic evaluation (ROSE) was used, cytologic diagnostic yield was 126/149 (85 %) with a median number of 3 passes; without ROSE, cytologic diagnostic yield was 31/45 (69 %, P = 0.03) with a median number of 3 passes. Overall, a pathologic diagnosis was rendered in 130/147 (88 %) specimens with a median number of 2 passes. Pathologic diagnostic yield for specific lesion types: pancreas 70/81 (86 %), subepithelial lesion 13/15 (87 %), lymph node 26/28 (93 %). Ten patients (10/226, 4 %) experienced adverse events: 4 acute pancreatitis, 5 pain, 1 fever/cholangitis. Conclusions: Initial experience with a novel EUS core biopsy needle demonstrates excellent pathologic diagnostic yield with a minimum number of passes.

Triple Pancreatic Walled-off Fluid Collections Treated Simultaneously with Endoscopic Transmural Drainage

Pancreatic pseudocysts and walled-off pancreatic necrosis arise as a complication of pancreatitis. Multiple fluid collections are seen in 5-20% of the patients who have walled-off peripancreatic fluid collections. There is a paucity of data regarding the role of endoscopic transmural drainage in the management of multiple pancreatic fluid collections. In this case report, we present the case of a 72-year-old male with three walled-off pancreatic fluid collections in the setting of acute necrotizing pancreatitis. The patient underwent simultaneous endoscopic ultrasound-assisted cyst gastrostomy and cyst duodenostomy and aggressive irrigation without index endoscopic necrosectomy of the three peripancreatic fluid collections. Significant improvement in the size of the fluid collections was seen on the computed tomography scan, as well as a remarkable immediate clinical improvement after 24 hours of the endoscopic intervention.

Rare presentation of a massive intermittent upper gastrointestinal bleed

Introduction: Hemosuccus pancreaticus is a rare cause of upper gastrointestinal bleeding defined as bleeding from the ampulla of Vater through the main pancreatic duct, commonly caused by a ruptured aneurysm in the setting of acute or chronic pancreatitis. Bleeding is often intermittent and repetitive, but can be massive. Endoscopy rarely reveals active hemorrhaging. Case Report: We present a 35-year-old male with complaints of progressive fatigue and generalized weakness over two weeks. He denied melena, hematochezia, and hematemesis. History revealed prior alcohol abuse and hospitalization for pancreatitis. Laboratory studies revealed hemoglobin of 2.8 g/dL. Initial esophagogastroduodenoscopy (EGD) revealed actively bleeding mass at the major papilla and absence of gastric/esophageal varices. Colonoscopy revealed no pathology. Bleeding continued and patient developed mild epigastric tenderness. Repeat EGD revealed a clean based ulcer in the distal esophagus and thickening of the duodenal mucosa, but no bleeding. Duodenal biopsies showed signs of chronic inflammation. Abdominal computed tomography scan revealed pancreatitis and splenic artery pseudoaneurysm. Patient underwent an abdominal aortogram, revealing an 8 mm splenic artery pseudoaneurysm with no active bleeding. The pseudoaneurysm was embolized and repeat imaging confirmed no residual pseudoaneurysm. Conclusion: Pseudoaneurysm resulting from a pseudocyst secondary to pancreatitis forms most commonly in the splenic artery. Mortality can be as high as 90–100% if left untreated. Although rare, hemosuccus pancreaticus should be included in the differential diagnosis for any patient presenting with severe anemia, in the absence of endoscopically visualized bleeding and with a history of pancreatitis. (This page in not part of the published article.) International Journal of Case Reports and Images, Vol. 8 No. 1, January 2017. ISSN – [0976-3198] Int J Case Rep Images 2017;8(1):30–35. www.ijcasereportsandimages.com Patek et al. 30 CASE REPORT OPEN ACCESS Rare presentation of a massive intermittent upper gastrointestinal bleed Bonnie Patek, Matthew Sullivan, Shashin Shah

Agreement between endoscopic ultrasound-guided fine-needle aspiration and endobiliary brush cytology in suspected pancreaticobiliary malignancies

Background and study aims  For suspected pancreaticobiliary malignancies, endobiliary brush cytology during endoscopic retrograde cholangiopancreatography (ERCP) remains the diagnostic test of choice despite historically poor and variable sensitivity. This has led to increased use of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) as an initial test. Recently, our institution began using a cytology brush that was designed specifically to collect a more substantial and higher-quality sample. The aim of this study was to investigate whether this brush design would provide more adequate samples and have high agreement with EUS-FNA in patients who underwent both procedures. Patients and methods  A retrospective chart review was conducted of all patients who underwent both EUS-FNA and endobiliary brush cytology for suspicion of pancreaticobiliary malignancy from January 2013 to May 2015. A total of 41 patients met the inclusion criteria. Initially, sample quality was evaluated. Final cytology results were then assessed for agreement with EUS-FNA using Cohen’s kappa. The effect of considering atypical cytology as negative was also uniquely evaluated by running separate analyses. Results  Brush cytology provided an adequate sample in 95.1 % of cases. Cohen’s Kappa demonstrated moderate agreement between brush cytology and EUS-FNA: κ = 0.42 ( P  = 0.001). When atypical results were excluded, agreement increased: κ = 0.60 ( P  = 0.02), but remained moderate. If atypical results were considered “positive,” the two procedures demonstrated equal cancer detection rates of 80.8 %. Conclusions  The studied brush provided more adequate samples compared with historical rates for brush cytology and had moderate agreement with EUS-FNA. If this brush truly increases sample adequacy, it could potentially provide results comparable to EUS-FNA at lower cost.